How to manage severe dehydration in a 5-year-old pediatric patient weighing 10 kg with gastroenteritis in the emergency room (ER)?

Management of Severe Dehydration in Pediatric Gastroenteritis

For a 5-year-old child weighing 10 kg with severe dehydration due to gastroenteritis, immediate intravenous rehydration with isotonic crystalloid boluses should be initiated in the emergency room, followed by admission to a pediatric ward for continued management and monitoring. 1

Initial Assessment and Emergency Management

Assessment of Dehydration Severity

• Signs of severe dehydration (≥10% fluid deficit) include:
  • Severe lethargy or altered mental status
  • Prolonged skin tenting (>2 seconds)
  • Cool and poorly perfused extremities
  • Decreased capillary refill
  • Rapid, deep breathing (sign of acidosis)
  • Weak or absent pulses 1, 2

Immediate Interventions

1. Establish IV access immediately - may require two IV lines or alternate access sites (venous cutdown, femoral vein, intraosseous) in case of difficult access 1

2. Administer IV fluid boluses:

   • Give isotonic crystalloids (Lactated Ringer's or normal saline)
   • Administer 20 mL/kg boluses until pulse, perfusion, and mental status normalize
   • For this 10 kg child, each bolus would be 200 mL 1, 2

3. Monitor response:

   • Reassess vital signs, capillary refill, mental status after each bolus
   • Continue boluses until clinical signs of hypovolemia improve 2

4. Laboratory assessment:

   • Check serum electrolytes, BUN, creatinine
   • Adjust electrolytes and administer dextrose based on chemistry values 1

Subsequent Management

After Initial Stabilization

• Once the patient's level of consciousness returns to normal:

  • Transition to oral rehydration for remaining deficit if the patient:
    • Has no risk factors for aspiration
    • Has no evidence of ileus
    • Is awake and alert 1

• Replacement of ongoing losses:

  • For a child >10 kg: Provide 120-240 mL ORS for each diarrheal stool or vomiting episode
  • If unable to drink, administer either through a nasogastric tube or continue IV fluids with 5% dextrose 0.25 normal saline with 20 mEq/L potassium chloride 1

Admission Decision

• This severely dehydrated 5-year-old child should be admitted to the pediatric ward for:
  • Continued monitoring of hydration status
  • Ensuring adequate fluid replacement
  • Monitoring electrolyte abnormalities
  • Assessing response to therapy 1, 2

Nutritional Management

• Once rehydration is complete:

  • Resume maintenance fluids
  • Offer age-appropriate normal diet every 3-4 hours
  • Do not dilute formula if the child was previously on formula 1

• Early reintroduction of usual foods has been shown to shorten the illness 3

Common Pitfalls to Avoid

1. Delaying IV therapy in severe dehydration - this is a medical emergency requiring immediate intervention 1

2. Using inappropriate fluids - avoid regular sodas, fruit juices, and sports drinks as they can worsen diarrhea and electrolyte imbalances 2

3. Neglecting ongoing losses - fluid losses must be continuously replaced as long as diarrhea or vomiting persists 1

4. Failing to monitor electrolytes - children with severe dehydration often have significant electrolyte disturbances requiring correction 2

5. Overlooking the transition to oral rehydration - once stabilized, transition to oral rehydration when appropriate to reduce complications of IV therapy 1, 4

Follow-up Care

• Monitor for:

  • Resolution of diarrhea and vomiting
  • Adequate urine output
  • Normalization of vital signs
  • Improvement in clinical appearance
  • Electrolyte balance 2

• Provide parent education on:

  • Signs of recurrent dehydration
  • Appropriate home fluid management
  • When to return for reassessment 3